Provider Demographics
NPI:1750401683
Name:ANDERSON, SHANNON RENEE (MA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CENTER ST # A
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MA
Mailing Address - Zip Code:01351-8912
Mailing Address - Country:US
Mailing Address - Phone:413-367-9694
Mailing Address - Fax:
Practice Address - Street 1:130 COLRAIN RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-9625
Practice Address - Country:US
Practice Address - Phone:413-774-3724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7009235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist